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Medication Errors in Critically Ill Adults: A Review of Direct Observation Evidence

Panagiotis Kiekkas, Mary Karga, Chrisoula Lemonidou, Diamanto Aretha and Menelaos Karanikolas
Am J Crit Care 2011;20:36-44 doi: 10.4037/ajcc2011331
2011 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

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AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright 2011 by AACN. All rights reserved.

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Patient Safety Issues

ERRORS IN CRITICALLY ILL ADULTS: A REVIEW OF DIRECT OBSERVATION EVIDENCE


EDICATION
By Panagiotis Kiekkas, RN, MSc, PhD, Mary Karga, RN, MSc, PhD, Chrisoula Lemonidou, RN, MSc, PhD, Diamanto Aretha, MD, and Menelaos Karanikolas, MD, MPH

2011 American Association of Critical-Care Nurses doi: 10.4037/ajcc2011331

Objective To systematically review clinical evidence gathered by direct observation of medication errors in adult patients in intensive care units. Methods Articles published between 1985 and 2008 in Englishlanguage journals indexed by the Cumulative Index for Nursing and Allied Health Literature and PUBMED were searched for studies on medication errors made by intensive care unit nurses. Studies in which errors were detected via direct observation were included. Results Six studies met the inclusion criteria, and error incidence varied considerably among them. Wrong dose, wrong administration time and rate, and dose omission were the most common errors. Antibiotics, electrolytes, and cardiovascular drugs were commonly associated with errors, but the evidence about factors contributing to errors was inconclusive. Increased monitoring was the most common consequence of medication errors, whereas life-threatening and fatal adverse events were rare. Conclusions Identification of patterns and characteristics of medication errors can guide preventive interventions. Factors contributing to errors, as well as drugs and error types associated with severe adverse events, deserve further investigation. (American Journal of Critical Care. 2011;20:36-44)

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lthough patient safety has always been a primary concern for health care professionals, it is mainly within the past decade that international reports have linked errors by medical-nursing personnel to adverse events and adverse outcomes for patients.1-3 This link is especially true in critical care, where nurses have to meet the demands of high-risk patients and administer a wide variety of pharmacological agents by multiple routes. The intensive care unit (ICU) is a complex environment, where the amount of cognitive information needed to reach a correct decision is high and often exceeds the upper limit of information that can be held in conscious memory.4 Beyond the complexity of the ICU environment, critically ill patients are particularly susceptible to the consequences of errors, as they may be unable to compensate for additional injury because of limited physiological reserve.5

Medication errors have been defined as preventable mistakes in prescribing or delivering medication to a patient, that is, an improper use of medicine or one that causes harm to a patient.6 Of importance, a medication error is independent of the occurrence of patient injury (or of the potential for injury).7 Although medication errors may occur at any stage of the medication process, most occur at the administration stage.8 Drug administration constitutes a high-responsibility, primary nursing task that can consume up to 40% of clinical nurses work time.9 Errors associated with drugs can be particularly common in the ICU. Critically ill patients receive nearly twice as many medications as patients in general care units, and most medications involve calculations for bolus administration or continuous infusion.10,11 Methods used for detecting medication errors vary. In a study where true medication errors in the ICU were recorded by an independent pharmacist, Flynn et al12 found that direct observation by trained personnel (mainly pharmacists) was significantly more valid and accurate than reviewing charts (by investigators) and incident self-reporting (by medicalnursing personnel). Comparison of the 3 error-

detection methods revealed that 65.6% of true errors were detected via direct observation, whereas only 3.7% were detected via chart reviewing and 0.2% were detected via self-reporting of incidents. Error incidence could be underestimated because of unrecorded information in chart reviewing and because of subjective error assessment by untrained personnel in incident self-reporting. The aim of this literature review was to synthesize the existing empirical evidence about medication errors occurring in adult ICU settings, focusing on the incidence, types, and clinical consequences of medication errors; drugs associated with medication errors; and factors contributing to medication errors. This review was limited to studies in which direct observation was used to detect medication errors, because that method is highly reliable for detecting errors.12

Materials and Methods

About the Authors


Panagiotis Kiekkas is an assistant professor in the nursing department at the Highest Technological Educational Institute of Patras, Patras, Greece. Mary Karga is an infection control nurse at Patras University Hospital, Patras, Greece. Chrisoula Lemonidou is a professor in the nursing department at the University of Athens, Athens, Greece. Diamanto Aretha is an anesthesiologist at Pyrgos Hospital, Pyrgos, Greece. Menelaos Karanikolas is an assistant professor of anesthesiology and critical care medicine in the University of Patras School of Medicine, Patras, Greece. Corresponding author: Panagiotis Kiekkas, 76 Stratigou Konstantinopoulou Str., Aroi, Patras 263-31, Greece (e-mail address: kiekkpan@otenet.gr).

Articles published between January 1985 and December 2008 in English-language journals indexed by the Cumulative Index for Nursing and Allied Health Literature (CINAHL) and PUBMED (National Library of Medicine) were systematically searched for clinical studies of medication errors in critically ill adult patients. Additional articles were retrieved from the reference lists of the articles found through the initial online search. A combination of the following terms was used in the search: errors, medication/drug errors, medication/drug safety, critical /intensive care unit, ICU/CCU, critically ill, and adult. Specific criteria used to select studies for this review were as follows: Types of study settings: critical/intensive care settings for adult patients, that is, medical, surgical,

True medication errors were detected 65.6% by direct observation, 3.7% by chart review, 0.2% by self-report.

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Table 1 Study characteristics and appraisal criteria


Stage(s) of medication process studied Preparation, administration Personnel informed of observation purpose No Observer characteristics and training 1 pharmacist trained in direct observation

Author (year), country, setting Fahimi et al13 (2008) Iran 12-bed mixed intensive care unit (ICU) Kopp et al14 (2006) United States 16-bed medical/ surgical ICU Herout and Erstad15 (2004) United States 16-bed surgical ICU Tissot et al16 (1999) France 15-bed medical ICU Van den Bemt et al17 (2002) The Netherlands 2 mixed (11- and 7-bed) ICUs Calabrese et al18 (2001) United States 5 medical, surgical or mixed ICUs (100 beds in total)

Data collection period 16 randomly selected shifts Data collection during peak times of intravenous drug administration

Observation design During a shift, 1 pharmacist observed 1 randomly selected nurse

Prescription, transcription, dispensation, administration Administration (continuous infusion)

Yes

16.5 days (33 12-hour shifts): 24-hour pilot stage and four 4-day periods 24 hours per day (2 sequential 12-hour shifts) 1 month, 202 medication infusions in total

2 pharmacists specialized in ICU pharmacy practice Not reported

During a shift, 1 pharmacist observed 1 randomly selected nurse

Not dened

All continuously infused drugs were evaluated at least once daily

Preparation, administration

Yes

30 days during a 2-month period, excluding weekends and nights 6 hours per day (heaviest periods for drug preparation and administration) 5 consecutive days (Monday to Friday), from 7 AM to 10 PM

2 pharmacists

Every day, 2 pharmacists observed 2 nurses

Preparation, administration

No

2 pharmacists trained in disguised observation Pharmacists being ICU specialists (pharmacy students in 1 ICU)

Every day, 1 pharmacist observed all nurses

Preparation, administration

No

3 months, limited to weekdays, nonconsecutively (depending on observers discretion)

Data collection occurred twice daily (morning / afternoon) on every ICU patient

or mixed ICUs. Studies conducted in pediatric or neonatal ICUs were excluded. Types of study design: prospective, single-center or multicenter, in which direct observation was used for data collection. Types of study subjects: nurses employed in ICUs. Types of exposure: medication errors occurring during drug prescription, preparation, dispensation, or administration. Studies in which medication errors were not separately reported (not distinguished from other error types) were excluded. Studies that included only medication errors that led to adverse events also were excluded (these errors may not have been representative of total medication errors). Retrieved studies were screened for inclusion by 2 independent reviewers (P.K., M.K.) by using

the titles and abstracts of the articles reporting the study results. When the reviewers disagreed about a particular study, a final determination was made jointly by both reviewers. Data extracted from selected studies were categorized according to the incidence, types and clinical consequences of medication errors, drugs associated with medication errors, and factors contributing to errors. Main study characteristics and findings are summarized in Tables 1 and 2. Because the heterogeneous nature of these studies did not allow data to be combined in a meta-analysis, a narrative literature review was preferred.

Results
Study Characteristics and Design A total of 6 studies13-18 (Table 1) were considered appropriate for this review. Three studies14,15,18 were

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Table 2 Study ndings on medication errors


Number (incidence) Contributing factors

Author (year) Fahimi et al13 (2008)

Types

Associated drugs

Consequences Not reported

% of errors/drug obser- Most errors at 9 380 errors per Wrong administration rate, AM administravations (corrected for 524 drug 43.4%; wrong continuous tion time, due opportunities for observations infusion rate, 23.0%; to nursing diserror): amikacin, (72.5%) and wrong dose (or diluent caltractions and 11.0%; vancomycin, per 4040 culation), 20.1%; inapproworkload peak 8.2%; diazepam, opportunities priate diluents, 11.2% 7.4%; metoclofor error (9.4%) pramide, 7.4%; metronidazole, 7.4%; ranitidine, 7.4%; ciprooxacin, 6.1% 172 errors per Clinically important medica645 drug tion errors (n = 132): dose administrations omission, 30 (22.7%); (26.7%) wrong dose, 26 (19.7%); wrong drug, 21 (15.9%); wrong technique, 20 (15.2%); drug-drug interaction, 13 (9.8%); wrong administration time, 12 (9.1%) 26 errors per 208 Drug omitted from ow continuous sheet, 57.7%; wrong or no drug infusions concentration reported, (12.5%) 19.2%; wrong continuous infusion rate, 15.4%; new order not reected on ow sheet, 7.7% Error proximal Medication errors cause: lack of leading to potential drug knowladverse events (n = edge, 23%; slips 110) - drug category and memory errors/total errors: lapses, 14%; cardiovascular, 17.3%; drug identicaantibiotics, 15.5%; tion error, 13%; sedatives/analgesics, rule violations, 13.6%; electrolytes, 11% 8.2%; endocrine, 7.3% Not reported

Kopp et al14 (2006)

Potential adverse events (n = 110): potentially fatal, 0.9%; potentially life-threatening, 8.2%; serious, 29.1%

Herout and Erstad15 (2004)

Calculation of Not severe 87.6% of doses for weight-based infusions was based on unreliable admission weights Not reported Potentially lifethreatening, 19.7%; need for increased monitoring, no patient harm, 41.7%

Tissot et al16 (1999)

Not reported 132 errors per Wrong dose, 38 (28.8%); 2009 drug wrong administration rate, administrations (intravenous, perfusion by (6.6%) gravity, or continuous infusion), 29 (22.0%); wrong preparation technique (incorrect dilution), 24 (18.2%); physicochemical incompatibility, 19 (14.4%); wrong administration technique, 10 (7.6%); wrong administration time, 9 (6.8%) 131 errors per Wrong administration time, Only gastrointestinal drugs were signi233 drug 52 (39.7%); wrong admincantly associated administrations istration technique, 36 with more errors (56.2%) (27.5%); wrong dose (odds ratio, 2.94; (preparation or administra95% condence tion), 33 (25.2%); dose interval, 1.48-5.85) omission, 7 (5.3%)

Van den Bemt et al17 (2002)

More errors on Need for increased Monday because monitoring, no of personnel patient harm, shift change 38.2% Specialized physicians and use of protocols possibly contributed to lower error rate Not reported Need for therapy or intervention, temporary harm, 1.1%; need for increased monitoring, no patient harm, 2.7%

Calabrese et al18 (2001)

187 errors per Wrong continuous infusion 5744 drug rate, 75 (40.1%); dose administrations omission, 27 (14.4%); (3.3%) wrong administration time, 26 (13.9%); wrong dose, 22 (11.7%)

% of errors/drug observations: epinephrine, 7.9%; potassium chloride, 6.8%; digoxin, 5.8%; magnesium, 5.4%; lorazepam, 4.5%; norepinephrine, 4.3%

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Six studies from 4 different countries were included in the review.

conducted in the United States; the remaining studies were conducted in Iran,13 France,16 and the Netherlands.17 Errors were detected during medication preparation and administration stages in 4 studies,13,16-18 during all stages of the medication process in 1 study,14 and only during administration of continuously infused drugs in 1 study.15 Differences regarding design of included studies are summarized in Table 1. First, Herout and Erstad15 focused on the administration of continuously infused drugs, whereas Kopp et al14 studied all stages of the medication process of both continuously infused and intermittently delivered drugs. Second, only Calabrese et al18 conducted a multicenter study, whereas van den Bemt et al17 studied 2 ICUs. Third, the duration of data collection varied considerably among studies, from 6 hours16 to 24 hours14 per day and from 5 days17 to 3 months18 total. Fourth, use of the disguised-observation technique minimizes the bias that could be induced by the observers presence.19 Thus, the results of studies13,17,18 in which personnel were not informed about the exact observation aim may be more reliable. Fifth, in 5 studies, direct observation was conducted by pharmacists (Herout and Erstad15 did not report the observers profession), who were ICUspecialized pharmacy residents in 2 studies,14,18 and trained in direct or disguised observation in another 2 studies.13,17 Sixth, in 3 studies,13,14,16 each pharmacist observed only 1 nurse. Finally, in 2 studies, only the most commonly used13 or high-risk medications18 were observed; thus error detection was limited to predefined drug categories. Incidence and Types of Medication Errors Details about the number, incidence, types, and clinical consequences of medication errors; drugs associated with medication errors; and factors contributing to medication errors are presented in Table 2. In all 6 studies, error incidence was estimated on the basis of drug observations and ranged from 3.3% to 72.5%. Error incidence was also estimated on the basis of opportunities for error (calculated by adding all steps for potential errors during drug preparation and administration) in 1 study.13 Types of medication errors were reported in all 6 studies. In the studies where errors were observed during continuous drug infusion, wrong rate was reported in 4 studies and was the first,18 second,13 and third15 most common error type identified. Intermittently delivered drugs were administered intravenously, intramuscularly, subcutaneously,

orally, or via nasogastric tube. Regarding errors associated with intermittently delivered drugs, wrong dose was reported in 5 studies and was the first,16 second,14 and third13,17 most common type of error reported. Wrong administration time was reported in 4 studies and was the first17 and third18 most common error type found. Dose omission was reported in 3 studies and was the first14 and second18 most common error type found. Wrong administration rate was reported in 2 studies and was the most common error type found.13 Drugs Associated With Medication Errors The drugs associated with medication errors were reported in 4 studies. In 2 studies,13,18 each drug was separately evaluated and the percentage of errors associated with each drug per number of observations of this drug was presented. Fahimi et al13 found that 4 antibiotics (amikacin, vancomycin, metronidazole, and ciprofloxacin) were included among the 7 drugs most associated with errors. Calabrese et al18 found that 3 cardiovascular drugs (epinephrine, digoxin, and norepinephrine) and 2 electrolytes (potassium chloride, magnesium) were included among the 6 drugs most associated with errors. In the other 2 studies,14,17 drugs were studied in categories. Van den Bemt et al17 found that only gastrointestinal drugs were significantly associated with more errors. Kopp et al14 presented the percentage of each drug category errors per total errors that could lead to adverse events. Cardiovascular drugs, antibiotics, sedatives/analgesics, and electrolytes were the drug categories most associated with errors. Factors Contributing to Medication Errors The factors contributing to medication errors were reported in 4 studies. Nursing distractions and workload peak, lack of drug knowledge, and communication deficiencies were the main factors associated with errors in 1 study each.13,14,17 Comparison of the ICUs of 2 different hospitals suggested that the presence of full-time specialized physicians and the use of drug preparation and administration protocols in 1 ICU may have contributed to fewer medication errors (compared with the other ICU, which had no full-time physicians or drug protocols).17 Herout and Erstad15 found that unreliable measurements of patients weights at admission were associated with wrong dose calculation of continuously infused drugs. Clinical Consequences of Medication Errors The clinical consequences of medication errors were reported in 4 studies. A potentially fatal case

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was reported in only 1 study.14 Potentially lifethreatening adverse events were reported in 2 studies, corresponding to 8.2% of medication errors leading to adverse events14 and to 19.7% of total medication errors.16 In 3 studies, 41.7%,16 38.2%,17 and 2.7%18 of total medication errors led to the need for increased monitoring without temporary or permanent patient harm. In 1 study,18 1.1% of medication errors led to the need for therapy or intervention, with temporary harm of the patient.

Discussion
In this review, we focused on studies of medication errors in the ICU detected via direct observation, rather than on studies of adverse drug events. Adverse drug events have a more random occurrence than medication errors and are less statistically predictable. It seems very difficult to predict whether a medication error will lead to an adverse event, and adverse drug events are not always attributed to medication errors (eg, adverse drug events can be due to unpredictable allergic reactions). Medication errors are not only more preventable than adverse drug events,16 but they also reveal weaknesses in the process of care. Thus medication errors are more reliable indicators of staff performance and quality of patient care than are adverse drug events.20 From a nursing perspective, detection of medication errors can provide a valuable insight into unsafe practices and help identify opportunities for improvement. Besides their impact on patients morbidity and mortality, medication errors have a considerable economic and societal burden.5,21 Thus, a number of error-prevention strategies have been proposed to increase the safety of the medication process, including pharmacists participation in clinical rounds, having independent drug checks by many providers, and using barcode technology, medication reconciliation programs, or computerized order entry by physicians.7,22-24 However, proper redesigning of faulty systems should be based on an in-depth understanding of the epidemiology of medication errors.14 This knowledge can guide the application of error-prevention strategies and will allow more specifically targeted quality improvement efforts. Moreover, because the incidence of medication errors in a single ICU is generally low, error patterns and characteristics can more reliably be identified by reviewing data from several ICU studies.25 Synthesis of data on ICU medication errors will reveal most common error types, drugs associated with and factors contributing to errors, and serious error consequences, as well as provide implications for future research.

In existing studies, the incidence of medication errors is reported either per number of drug observations or per opportunities for error. Opportunities for error are difficult to define, but may properly reflect patients exposure to risk. Differences in health care provision (such as nurse:patient ratio, personnel experience, number and types of drugs administered, and medication delivery system) among different hospitals or countries may account for the remarkable differences in incidence of medication errors among studies.5 Reported error incidence also depends on the exact conditions of direct observation, on the exclusion of medication errors considered to be clinically unimportant,14 and on the selection of medication process stages to be studied (most studies13,16-18 have focused on errors during drug preparation and administration). Although definitions of medication errors may vary among studies, it is important that some error types were considerably more common than others. In remarkable agreement with findings of studies included in this review, the 3 most common medication error types in ICU studies that were based on workers voluntary self-report26,27 or chart review28 were wrong administration time and wrong or omitted dose, whereas administration of the wrong drug or administration to the wrong patient was generally rare. In particular, the incidence of wrong-dose errors could be underestimated in voluntary selfreport studies, owing to both workers difficulties in becoming aware of such errors and social desirability bias or self-esteem bias (because wrong-dose errors are primarily attributed to individual deficiencies, participants may tend to underreport them).29 Even in this case, it is important that wrong dose was among the 3 most common error types in another 2 ICU personnel self-report studies,25,30 thus indicating a similar trend between the direct observation and voluntary self-report methods. Tissot et al16 found the wrong administration rate to be the second most common type of error, but errors related to continuous drug infusion and errors related to intermittently delivered drugs were recorded together. Recording data in this fashion renders analysis and extraction of conclusions difficult, as an incorrect continuous infusion rate means not only that the patient will receive a drug faster or

Redesigning of faulty systems should be based on understanding medication error epidemiology.

Because medication error rates in a single ICU are generally low, error patterns should be reviewed over several ICUs.

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Wrong dose, dose omission, and wrong administration time are the most common error types.

slower than indicated (as in the case of wrong bolus administration rate), but that total administered dose will be inappropriate as well. Medication error types associated with continuous vs intermittent administration technique may not be comparable; therefore, these error types should be recorded separately in studies. High number of errors associated with antibiotics, for example, may simply reflect the high number of antibiotic doses administered to ICU patients. Thus, when evaluating whether a drug (or drug category) is particularly associated with errors, more valid comparisons might be based on the incidence of errors associated with this drug (ie, the number of errors per number of observations or per opportunities for error of this drug), rather than on the absolute number of errors associated with this drug (or on the proportion of errors associated with this drug per total medication errors). In addition, more focused error prevention could be achieved through the identification of specific drugs more often associated with errors (rather than the identification of drug categories associated with errors). However, no single drug can be identified as particularly associated with errors on the basis of existing data. Consistent with findings of studies included in this review, antibiotics, sedatives/analgesics, and cardiovascular drugs (vasopressors/catecholamines) were most commonly associated with errors in a recent, self-report, multicenter ICU study.26 Antibiotics in particular have been identified as the highest-risk drug category in non-ICU studies and are believed to be associated with a high incidence of wrong administration time errors or omitted doses, due to variations in the interval at which antibiotics are administered.31,32 Considering the multifactorial nature of medication errors, several predisposing factors have been investigated, which can be associated either with the individual (inadequate mathematical skills or medication knowledge, personal neglect, limited experience) or the system (eg, heavy workload, unfavorable working conditions, distractions, complicated orders).32,33 In critically ill patients, high clinical severity and high number of organ failures have also been associated with high incidences of errors.21,26 In agreement with findings of studies included in this review, poor communication, frequent interruptions, and workload have also been reported as the main factors contributing to errors

in interview or voluntary self-report studies among ICU personnel.34,35 However, existing findings of direct observation studies are rather inconclusive, because none of the identified error-contributing factors was reported in more than 1 study. Moreover, possible associations between specific errorcontributing factors and specific medication error types have not been investigated to date and may be an important area for future research. For example, wrong-dose errors may be attributed to inadequate mathematical skills or drug knowledge of nurses and preparation errors by pharmacists, whereas dose omission and wrong administration time may be mainly related to system factors, such as increased workload, drug availability, pharmacy preparation timing, and time constraints with competing priorities. According to Reasons model,36 most accident sequences are trapped at one or more layers of the systems defenses. In agreement with findings of studies included in this review, most ICU medication errors did not result in clinically significant consequences or patient harm in a voluntary selfreport study26 or in a review of safety incident reports of nursing staff.37 Considering that vital functions of ICU patients are continuously monitored and supported, most physiological disorders resulting from errors can be detected and properly treated at an early stage or may even require no additional treatment. For example, opioid overdose, which could cause severe respiratory depression in spontaneously breathing patients, may not considerably affect a patient receiving mechanical ventilation.25 Although only a limited proportion of medication errors have life-threatening or fatal consequences, the incidence of preventable adverse drug events is not insignificant, ranging from 19 to 36.2 per 1000 ICU patient-days in US studies.6,38 Moreover, late consequences of medication errors could be overlooked in studies, because adverse events are generally recorded proximal to the timing of medication administration. For example, the Joint Commission has emphasized the importance of effective timing of antibiotic administration in pneumonia core measures.39 However, although timely antibiotic administration is important in patients with severe infections, adverse patient outcomes associated with antibiotic dose omission or wrong administration time are not recorded in most studies.40 Meaningful questions for future research could include whether specific medication error types or drugs are associated with a high incidence of adverse events, both early and late, and particularly with life-threatening or fatal consequences.

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The small number of studies that met the inclusion criteria and the limited information about the characteristics of medication errors in some of the studies are the major limitations of this review. Another limitation is the heterogeneity of the studies, which used inconsistent definitions of errors and error incidence, were focused on different medication process stages or on different drug administration techniques, and involved different critical care settings. Additionally, although superior to other error detection methods, direct observation cannot capture errors completely. Flynn et al12 reported that with direct observation, 34% of true medication errors were missed and the rate of false positives (3.5%) was considerable.

SEE ALSO
For more about medication errors, visit the Critical Care Nurse Web site, www.ccnonline.org, and read the article by Anthony et al, No Interruptions Please: Impact of a No Interruption Zone on Medication Safety in Intensive Care Units (June 2010).

Conclusion
Data derived from studies of ICU medication errors via the direct observation method suggest that the incidence of medication errors varies significantly among ICUs. Identification of the most common error types, the drugs associated with errors, the factors contributing to errors, and serious consequences of errors, is necessary to guide focused efforts to prevent medication errors. Wrong dose, dose omission, wrong administration time, and wrong administration rate (especially of continuously infused drugs) are the most common error types. The most common drug categories associated with medication errors in the ICU included antibiotics, electrolytes, cardiovascular drugs, sedatives/analgesics, and gastrointestinal drugs. Distractions, high workload, lack of drug knowledge, and poor communication may contribute to errors. Although most medication errors do not result in harm of patients, life-threatening or fatal adverse events have been reported. Nursing personnel should design and lead future studies on their own medication errors. Research based on direct observation has yet to address many issues, mainly establishing the specific drugs most associated with medication errors and the factors contributing to medication errors in general or to specific types of medication errors. Investigation of medication error types most associated with severe adverse events is also of particular importance.
FINANCIAL DISCLOSURES None reported.

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